Eisenberg Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 24) was free from any significant medication errors by failing to administer Midodrine (a medication that increases blood pressure; used for residents with consistently low blood pressure) within the physician's prescribed parameters (specific instructions or limits set by a physician for how a medications should be given. Parameters may include when to give the medication or when to hold it). This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization. Findings: During a review of Resident 24's admission Record, the admission Record, indicated the facility originally admitted the resident on 11/20/2023 and readmitted on [DATE] with diagnoses including hypotension (abnormally low blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 24's Minimum Data Set (MDS-a standardized assessment and care screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship program (coordinated effort to ensure that antibiotics are prescribed appropriately, only when needed, in the correct dose, and for the right duration) for one of two sampled residents (Resident 26) by failing to ensure the resident's physician was notified when the resident who was prescribed an antibiotic did not meet the criteria for Skin and Soft Tissue infection (SSTI- bacterial, viral, or fungal infections that occur when germs enter breaks in the skin causing pain, swelling, redness, and warmth). This deficient practice had the potential for Resident 26 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 26's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 26 to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 3) whose primary and preferred language was not English. This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed. Findings: During a review of Resident 3's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 3 on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with agitation and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset. Resident 3's admission Record indicated primary language: Persian (foreign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their facility's policy on wheelchair use by failing to ensure staff locked residents' wheelchair brakes while residents were sitting on their wheelchair for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to place the residents at increased risk of sustaining an injury. Findings: a. During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 2 on 11/6/2023 and readmitted the resident on 7/14/2024 with diagnoses that included unspecified convulsion-seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [the state of being awake and aware of one's surroundings), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychotic (a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked while the medication cart was left unattended for one of two sampled medication carts (Medication Cart A). This deficient practice had the potential to result in unauthorized personnel or residents accessing the medications stored in the unlocked medication cart. Findings: During an observation on 2/27/2025 at 11:24 a.m., observed Medication Cart A parked in the nurse's station, unlocked, and unattended. Observed residents and other facility staff walking by the unlocked medication cart. During a concurrent observation and interview on 2/27/2025 at 11:25 a.m., with the Minimum Data Set Nurse (MDSN), observed Medication Cart A parked in the nurse's station. The MDS Nurse confirmed the observation and stated that Medication Cart A was unlocked and unattended. During a concurrent observation and interview on 2/27/2025 at 11:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Medication Cart A parked in the nurse's station. LVN 1 stated that Medication Cart A was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 61 and 64) were free from unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 61 had a specific, measurable target behaviors (the specific, undesirable behavior that a medication is intended to reduce or manage) related to the use of Zoloft (medication to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]). 2. Resident 64 had a specific, measurable target behaviors related to the use of Seroquel (medication used to treat mental illness). These deficient practices had the potential to place Resident 61 and Resident 64 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having two medication errors out of 32 opportunities contributing to an overall error rate of 6.25 % for one of nine residents (Resident 61) observed during the Medication Administration facility task. These deficient practices resulted in the omission of medications which could have resulted in severe health complications. Findings: During a review of Resident 61's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (high blood sugar), BPH, Parkinson's disease, dysphagia (difficulty swallowing), and presence of a G-Tube (a plastic tube inserted into the stomach to infuse medications for one who has problems swallowing). During a review of Resident 61' s Minimum Data Set (MDS, a resident assessment tool), dated 9/07/2024, the MDS indicated Resident 61 was severely impaired in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of nine residents (Resident 61) investigated during the medication administration facility task by failing to: 1. Ensure Registered Nurse 1 (RN 1) administered the medications Sinemet (two medications combined into one medication to treat Parkinson's disease [(a nervous system disorder which leads to movement problems) and terazosin (a medication to treat benign prostatic hyperplasia (BPH, a non-cancerous condition that causes the prostate [a gland in the male reproductive system] to enlarge due to an overgrowth of cells), for one (Resident 61) of nine residents observed during the medication pass observation. 2. Ensure Licensed Vocational Nurse 4 (LVN 4) administered finasteride and Sinemet during the 3 p.m. to 11 p.m. shift on 12/03/2024 to Resident 61 These failures had the potential for Resident 61 to experience unwanted adverse effects such as tremors, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to: 1. Store food in accordance with professional standards for food service safety by failing to: a. Label one container of oatmeal with a use by date label. b. Label one container of powdered sugar with a use by date label. c. Label one container of quinoa with a use by date label. d. Label one container of bulgur with a use by date label. e. Label one container of cream of wheat with a use by date label. f. Label one bag of lemon curd with a use by date label. g. Label one container of chicken with a use by date label. e. Label one container of ground beef with a use by date label. 2. Ensure the chlorine test strips used to check that the sanitizing solution was not expired. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: 1. During a concurrent observation and interview on 12/2/24 at 8:00 a.m., with the Dietary Supervisor (DS), observed in the storage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Observe infection control guidelines when Registered Nurse 1 (RN 1) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown for one (Resident 61) of 12 residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. Ensure Housekeeper 1 (HK 1) used the eye protective personal equipment (PPE-goggles or face shields used to prevent or minimize exposure to respiratory droplets [a small droplet of saliva or mucus that is produced when someone exhales]) while cleaning inside the resident's room for one (Resident 68) out one resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure the physician was notified of a resident's refusal of suprapubic catheter care for one of three sampled residents reviewed under the catheter care area. This deficient practice placed the resident at increased risk for infection. Cross reference F656 Findings: During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 4/4/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and status post suprapubic catheter placement. During a review of Resident 55's Minimum Data Set (MDS -a resident assessment tool) dated 10/10/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 55 was dependent on staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to: 1. Develop a care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and the prevention of worsening a condition, and current treatments) addressing a resident's refusal to wear a mask while on contact/droplet precautions (steps that healthcare staff take to prevent the spread of germs when a patient has germs that can spread through touching and coughs and sneezes) for one (Resident 40) out of five sampled residents investigated during review of the infection control task. This deficient practice had the potential to delay the provision of necessary care and services to Resident 40. 2. Develop a care plan addressing the resident's refusal of care of his suprapubic indwelling catheter (a flexible plastic tube inserted into the bladder from a small cut in the stomach, that remains in place to provide continuous urinary drainage) and failed to implement a care plan intervention to monitor the resident`s…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to revise a care plan addressing the removal of indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) for one (Resident 22) out of two sampled residents investigated during review of the catheter care area. This deficient practice had the potential to delay the provision of necessary care and services related to the resident's urinary catheter. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection where the infection-fighting processes turn on the body, causing the organs to work poorly), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). During a review of Resident 22's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a resident was provided a communication device with the language that the resident is able to understand for one of one sample resident (Resident 22) investigated under the communication care area. This deficient practice prevented the resident from communicating with the staff and had the potential to delay the appropriate care or treatment the resident needed. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection, where infection-fighting processes turn on the body, causing the organs to work poorly), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). The admission Record indicated Resident 22's preferred language…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) injury for one of three sampled residents (Resident 51) as evidenced by failing to monitor the functionality of the resident's low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) to ensure the LALM was working properly. This deficient practice had the potential for Resident 51 to develop a new pressure injury. Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility originally admitted the resident on 10/21/2021, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to act upon a recommendation from the Pharmacy Consultant (PC -a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) to clarify the behavior manifestation for the use of Seroquel (a psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 64) reviewed for unnecessary medication. This deficient practice increased the risk of receiving medication that was not optimal for Resident 64's medical condition and increased the risk of adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy. Findings: During a review of Resident 64's admission Record, the admission Record indicated the facility admitted the resident on 5/10/2024, with diagnoses including major depressive disorder a persistent feeling of sadness or a lack of interest in outside stimuli), dementia (a progressive state of decline in mental abilities), and psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles in one of (Second Floor, Medication Cart 2) four medication carts inspected when Resident 10's discontinued medication, amlodipine (a medication to lower blood pressure) was not removed from the medication cart and disposed of. This deficient practice had the potential for Resident 10 to receive this medication which could have lowered the blood pressure below normal limits causing dizziness, and loss of consciousness. Findings: During a review of Resident 10's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease (a group of heart problems that develop over time due to high blood pressure). During a review of Resident 10' s Minimum Data Set (MDS, a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 10 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility had arranged provisions of hospice (a type of medical care for residents who are in the last stages of life) services by failing to: 1. Ensure hospice staff signed the hospice Interdisciplinary Team Sign-in Sheet upon arriving to the facility for one of three sampled residents (Resident 1). 2. Ensure a hospice Interdisciplinary Team Sign in Sheet was placed in the chart for one of three sampled residents (Resident 3). 3. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual agreement. This deficient practice has the potential to negatively affect Resident 1 and Resident 3's physical comfort, psychosocial (the state of mental, emotional, and social health of an individual) well-being, and has the potential to delay or have a lack of necessary care and services. Findings: 1. A review of Resident 1's Face Sheet indicated the facility originally admitted the resident on 12/2/2013 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to: 1. Ensure licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for two of four medication carts (Medication Team 1 Cart and Medication Team 2 Cart) observed during medication storage. 2. Ensure a resident's Controlled Medication Count Sheet (a form that is signed at the time a licensed nurse gives a controlled medication to a resident, in order to account for each medication) was signed at the time a medication was given for one of one sampled resident (Resident 65). These deficient practices had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications. Findings: 1.a. During a concurrent interview and record review on 12/11/2023 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure a blood pressure (the pressure of circulating blood against the walls of blood vessels) was checked prior to administering losartan (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) that had a hold (do not give) parameter to hold for systolic blood pressure (SBP, measures the force the heart exerts on the walls of the arteries each time it beats) less than (<) 110 mm Hg (millimeters of Mercury, a unit of measure for blood pressure) for one of five sampled residents (Resident 2). This deficient practice had the potential to result in hypotension (low blood pressure) which can result in confusion, dizziness, and fainting and require further treatment including hospitalization. Findings: A review of Resident 2's Face Sheet (admission record) indicated the facility admitted the resident on 6/30/2023, with diagnoses that included hypertensive heart disease (weakening the heart from chronic blood pressure elevation, making it harder to pump blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide dignity and respect when Registered Nurse 1 (RN 1) was observed wearing gloves and standing over two of four sampled residents (Resident 40 and 64) while assisting each resident with feeding. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 40's Face Sheet (admission Record) indicated the facility readmitted the resident on 1/20/2020 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), history of falling, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/7/2023, indicated Resident 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for one of three sampled residents (Resident 64) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care. Findings: A review of Resident 64's Face Sheet (admission record) indicated the facility admitted the resident on 12/8/2022 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (he loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and chronic rhinitis (a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). A review of Resident 64's Minimum Data Set (MDS - a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to monitor a resident's behaviors who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental disorder characterized by a disconnection from reality]) for one of five sampled residents (Resident 123) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (unwanted undesirable effects related to a medication) or impairment in the resident's mental or physical condition. Findings: A review of Resident 123's Face Sheet (admission record) indicated the facility admitted the resident on 11/29/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), psychosis, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 123's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/5/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure liquids were prepared in a form designed to the meet the needs for one of two sampled residents (Resident 18) observed during the Dining Observation task by failing to ensure nectar thick liquids (a thickening agent is added to liquids for people with difficulty swallowing and at risk for aspiration [accidentally inhaling food or liquid through the vocal cords into the airway]) were prepared and served to the resident. This deficient practice had the potential to result in aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, or liquids) in Resident 18. Findings: A review of Resident 18's Face Sheet (admission record) indicated the facility admitted the resident on 10/3/2022 and readmitted the resident on 8/15/2023 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.